Inquest into the death of Mohamed Warwar

Case Number: 2021/302441

Date of Findings: 21 May 2024

Magistrate: David O'Neil

CORONIAL LAW | death in custody; natural causes; HPNFs; record keeping; communication between correctional officers and nursing staff

Responses

Recommendations to	Response
Acting Commissioner Corrective Services NSW	Received (PDF, 839.2 KB)
Chief Executive Justice Health and Forensic Mental Health Network	Received (PDF, 583.0 KB)

Recommendations

Acting Commissioner of Corrective Services

1. Consideration be given to ensuring Health Problem Notification Forms (HPNF) are easily available and accessible to staff managing inmates in accommodation areas.

2. Consideration be given to:

a. the deficiencies in practice and procedure revealed in the evidence such as,

i. not attending handover;

ii. failing to keep appropriate records; and

iii. correctional officers not referring to HPNFs,

b. the qualifications, training, and experience of those responsible for the deficiencies,

c. the policies and/or other documentation directing attention to the correct practice and procedure, and

d. the volume of policies and training that employees are currently exposed to, with a view to exploring and implementing better ways to minimise the risk of employees not following policy and deficiencies being repeated.

3. That there be mandatory refresher training on HPNFs for all current and future serving Correctional Officers. The frequency of the mandatory refresher training is to be determined after consultation with relevant stakeholders.

Chief Executive of the Justice Health & Forensic Mental Health Network

4. Consideration be given to:

a. the deficiencies in practice and procedure revealed in the evidence such as,

i. not attending handover;

ii. failing to keep records; and

iii. not filling in HPNFs appropriately;

b. the qualifications, training, and experience of those responsible for the deficiencies,

c. the policies and/or other documentation directing attention to the correct practice and procedure, and

d. the volume of policies and training that employees are currently exposed to, with a view to exploring and implementing better ways to minimise the risk of employees not following policy and deficiencies being repeated.

5. That there be mandatory refresher training on HPNFs at least once every 2 years for all current and future serving Justice Health clinical staff statewide.

6. That a shadow study be undertaken to determine what work is required on a regular evening shift at Metropolitan Remand and Reception Centre (MRRC), where time pressures arise, and what support would best assist staff on evening shift.

7. That once the shadow study has been undertaken, steps be taken to put in place the identified support requirements.